The purpose of this blog is to gather information about how to support caregivers of children. The quality of the caregiving relationship in infants and young children, central to the healthy development of the growing child, can be enhanced by attention to the caregivers in the form of education and other support. This blog will become an archive for information on these issues.

Tag Archives: LEPINA

Let me tell you about a child in another home. This 9-year old girl, “Miranda”, is by all accounts an intelligent child, who only just gets by in school. She is very distractible and misses a lot of what is said in class. In recess she is usually alone. When the students are asked to work in a group, she will hang back until the teacher assigns her a place in a group and then she will initially not participate. Only when she becomes comfortable with the other children will be begin to contribute. Recently, she began ask permission to go to the bathroom multiple times during the school day. The teacher, who is generally sympathetic and supportive of Ines, decided to limit her bathroom permissions to two per day. Since then, Miranda has complied with the limit.

At the home, her moods are up and down. There are two times when she presents a particular problem for the caregivers. The first is in waking up in the morning. Typically she will hide under the covers and refuse to get up when waked. Sometimes she will scream for the caregiver to go away. If the caregivers try to physically help her out of the bed and into the shower, she can escalate to an alarming degree. It is an excruciating ordeal for all involved. The second problem is that sometimes when she is in a bad mood she will be hypersensitive to touch and accuse a caregiver of “hurting” her. One time she accused a caregiver of grabbing her in her private parts, an act that the caregiver vigorously denied.

This is the story of the Miranda’s life. She entered the children’s home at 3-years old. While in the home of her biological family, she witnessed much domestic violence. A relative confided in the director that she suspected a male relative had sexually abused Ines, though this had not been confirmed. In my last visit to the home, Ines had been playing with a caregiver and another girl, creating something out of paper and a cardboard box. She would describe what she was making as she worked, saying that she needed band aids, medicine, etc. Another girl was helping her by meticulously covering the box with clean white paper, according to Ines’ instructions. When I asked what she was making, Ines explained that she was making a “botoquin”, a first aid kit. Miranda and her brother had just returned from a weekend “home” with her relatives. Her brother had told the caregivers that the adults in the home continued to be abusive. In her play about the botoquin, I thought Miranda was telling us that she felt “hurt” by the visit and that after returning to the home, she felt safe.

I was touched by Miranda’s botoquin play and thought of her during the time between my visits. I worried about the terrible tantrums she had in the morning and how it stressed the caregivers at the home, who were trying to help her get to school. She behaved as if they were torturing her. Actually, that is what gave me another idea. Maybe she was also telling us something in her morning meltdowns. Maybe, she was “triggered” by the act of being waked her up and physically pulled out of bed. Maybe, though it was not in her conscious mind – as Van der Kolk says, her “body keeps the score” – being taken out of bed when she was sleeping and sexually abused. Of course, we cannot know for sure, but her reaction at being wakened to go to school seems suggestive of that.

During this visit, I was looking forward to seeing more of her play. I thought of setting up a play interview, but what transpired was far better. On the way back from an activity, Miranda was in the back seat of the car with three other children. They were playing with barbie dolls – making them talk, negotiate friendships and disputes. This was the beginning of a doll play that lasted the rest of the day. When we returned home, she and the other girls moved the play into the girls’ bedroom. There they established themselves on the bottom bunk of one of the beds and continued the story of the several barbies and one ken. They played that the barbies belonged to families that were friends with each other. There were various events in their family lives, particularly birthdays that the families celebrated.

Each girl had her unique contribution to the play as well as collaborations. One little girl I will call “Daniela”, kept calling out for her mother. “Mommy!” she would call to the Barbie designated as the mother, “Come to my party!” They would plan for a birthday party, but for some reason – she was sick or busy – the mother Barbie would never come, and Daniela’s plaintive crying for her would continue.
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This play illustrates one of the ironies of LEPINA. The girls were playing about families, but I wondered what was the meaning of family in their minds? What was the meaning of the “Mommy” in Daniela’s play? The reality of Daniela’s life is that she had been given to the children’s home when she was a sick newborn and had been loved and nursed back to health by a caregiver in the orphanage, who continued to have a primary caregiving relationship with her until she was 6-years old. Her biological mother, a mentally fragile young woman with whom Daniela had a distant relationship, would visit from time to time and was content with Daniela’s staying at the home. When Daniela was 6-years old, LEPINA was implemented and Daniela was required to return to her biological family. The court deemed her mother ill equipped to care for her and gave her custody to her aunt, who had children of her own. Although she was well meaning, her aunt was moody and often lost her temper or was harsh with Daniela, behavior Daniela had not experienced from her gentle caregiver at the home. The biggest problem, though, was the separation from her functional “Mommy”. The disruption of the caregiving relationship caused grief to both Daniela and her caregiver. As is typically the case, once the courts made the recommendation, there was no real follow-up, no support for the aunt except for what the home tried to provide in terms of groceries or rides to school. When Daniela was allowed to spend the weekend at the home for a visit, it was bitter sweet, because both Daniela and her caregiver knew that their time together was limited and soon there would be another painful goodbye.

Anyway, back to Miranda. Miranda had her own unique contribution to the play. Before settling down with the doll play, she carefully prepared an enclosed space by fastening blankets and bedspreads under the mattress of the upper bunk so that the lower bunk was like a little tent. This was time-consuming, and she worked carefully at it, sometimes tucking in several layers of fabric. After a while, the other girls became disconnected from the game and either left or got involved in other aspects of the play. By contrast, Ines continued her work, opening drawers to get blankets, tucking them under the mattresses, making the enclosure more and more “secure”. As I watched her in fascination, I realized that she was playing another version of the botoquin game. She was trying to make a safe place. However, in contrast with the botoquin play, in which she was collaborating with another girl and chatting with cheerful, animated affect, in this case there was a lonely, compulsive quality to her activity. The play theme was not elaborated. She was exhibiting what is called post-traumatic play, as described by a major contributor to the literature on child trauma, Lenore Terr.

As I watched her play, I recalled two other incidents related to Miranda. The first was years ago, when Miranda was about 6-years old. I recall her hiding in the playhouse of another children’s home and peeking out the window, like a frightened little animal. The director of the home told me that when both Miranda and her brother were highly stressed, they would sometimes huddle up and hide under the bed or in a closet. I also remembered the director of the home telling me about times in which Miranda appeared to lose touch with what was going on around her, and even seemed to faint – lose consciousness – on several occasions. The director had taken her to the doctor, but after examining her, the doctor suggested that she was fine, and that her behavior was probably hysterical or manipulative. On the plane to San Salvador, I had been rereading Bruce Perry’s The Boy Who Was Raised as a Dog, and I realized that most likely what the director had been describing to me was the physiological response of lowered heart rate and dissociation to a traumatic trigger (Perry, Szalavitz, 2006, pp. 172, 191).

On the last day of my visit, I sat down with the caregivers to talk about Miranda and what we might do for her at the home, in school, and in relation to family visits. One of the first steps, we thought, might be to talk to her teacher about what we thought was interfering with Miranda’s paying attention in the classroom so that she would have an empathic understanding of Ines’ challenges, and then trying to implement regulatory breaks into her daily classroom routine. It seemed to me that this is what she had been asking for in her requests to go to the bathroom (although there may also have been symbolic meaning involved). Another crucial step was to try to change her morning routine so that she would not have repeated traumatic experiences in the mornings at home in the waking up process, and so that her caregivers would not be extremely stressed by her frantic oppositional (subjectively, her self-protective) behavior. I will follow up these steps and others in further blog postings. Two important issues to be addressed in further postings are Miranda’s “manipulative” behavior in other contexts, and her episodic accusations of abuse by the caregivers in the home. I will also talk more about the home visits and how they should be planned with the best interest of the child in mind.

Perry B, Szalavitz M (2008). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook, Basic Books.

Transition from Foster Caregivers to Parent:
Luis is a 5-year old boy whose mother was a sex worker and gave him to her sister to care for when he was 1-year old. The sister was already taking care of Luis’ older sister, and she had two children of her own. When the sister moved in with a new boy friend, she could only take care of the sister and gave the then 2-year old Luis to a children’s home.

Luis’ mother was a young woman who had spent most of her childhood in a large orphanage, where she was alternatively neglected and abused. When she was 18 she left the orphanage and tried to find work but started using drugs with a boyfriend and became addicted. Unable to support her habit any other way, she became a sex worker. She first became pregnant with Luis’ sister and then with Luis, by different men. It is unknown whether she was using drugs during her pregnancies or whether the infants had problems at birth. The aunt did not notice any health problems in the babies, but did say that Luis was an irritable baby when he came to live with her at 1-year old. According to the aunt, Luis’ mother had wanted to care for him herself, especially after having to give up her first child, but her drug habit and her other activities resulted in her leaving him with neighbors and even strangers from time to time in a manner she herself acknowledged was neglectful.

When he entered the children’s home at 2-years old, he appeared to be a bright, engaging little boy who was, however, extremely anxious about losing control, for example, terrified of having an accident during potty training. This was despite the tolerant attitude the caregivers at the home had towards the toilet accidents of the toddlers. He seemed to thrive at the children’s home and became especially close to two other boys of the same age. He developed warm relationships with two female caregivers who worked with the “little boys” for the three years he was at the home. He loved the attention of the volunteers, especially the young men; some of them returned often to the home and developed real relationships with the children. Luis’ mother visited him in the home sporadically. He seemed pleased and interested in her visits, especially when she brought him presents, but as he got older he got upset when she brought the sister with her to visit and then mother and sister left together, even though the sister was actually living with the aunt.

When the LEPINA (http://www.unicef.org/about/annualreport/files/El_Salvador_COAR_2010.pdf , http://scrippsiij.blogspot.com/2012/12/lepina-law-harms-rather-than-helps.html) law was enacted in the country, it was ordered that he return to his mother. This was in spite of his mother not having a real home to take him to. The mother, anxious to have her son returned to her, told the court that she lived with her sister, and the court, anxious to comply with the law, accepted her statement. The children’s home was distressed at the decision, but they were unable to prevent Luis’ move back with his mother. They were worried not only that Luis would be leaving the home and his caregivers of three years, and not only that they deemed the mother incapable of caring for him at this time, but also they were afraid that the plans they had made for him to go to a good school would be jettisoned and that he would not begin school on time. They decided to work to build their relationship with his mother stronger and to try to support him in the neighborhood, but they were not optimistic.

How do you imagine that the Home could support this caregiver-child pair?

I am in El Salvador and am reporting on a recent workshop I gave at the children’s home, Love and Hope, with my colleague and team member, Susana Fragano. Before my departure for El Salvador, I asked Rachel, in one of our regular skypes, what she and the tias and tios (caregivers) would like to have as the focus of the workshop. She said that what they really needed help with was how to manage severe behavior problems. She told me about some of the tantrums, insolence and noncompliance, and sexual behavior, of the children in the home. This behavior has gotten worse in the last year or so since LEPINA, the Salvadoran law that requires institutionalized children to be reunited with their biological families, has been implemented, causing most of the children in the home to be returned to their families in the community. These reunited children, when they return to the home at the request of their families – either for weekend visits or for longer stays – because the families declare themselves unable to care for them – demonstrate more problematic behavior than before the reunification. Whether the worsening in behavior is due to neglect and abuse the children report they have experienced during the time they were living with their families, whether it is a consequence of the disruption of a secure caregiving environment and the traumatic loss of the caring relationships they had enjoyed at the home, or whether it is simply due to their growing older, is not known.

In the next several blog postings I am going to report on my experiences at the home during this visit and the workshop we gave to the caregivers. For a reason that will become clear as I continue, I will call these postings, “A Healing Place”. I have awakened early to write, and as I open the curtains in the window of my favorite hotel in San Salvador, I look out on dark mountains in the near distance, palm trees and other tropical vegetation in the nearer distance, and the “Mister Donut” sign that protrudes above the rooftops and guides us home after a day’s work.

Pathway to Trouble

I introduced the workshop with a review of the sources of the problems that these troubled children now have. I reminded them of the important factors I have spoken to them about many times before: (1) Prenatal stress; (2) Early abuse and neglect; (3) A genetic contribution; (4) and the ongoing trouble caused by the effect of chronic stress on the developing brain. The more you repeat a problem behavior, the better your brain learns to repeat it. I would like to state at the beginning of this series of posts that many of the points I am making about traumatized children are equally valid in relation to children with serious developmental disturbances, such children on the autistic spectrum. That is because for these children ordinary life experiences with other people, even caring attention, can feel traumatizing.

Interrupting that Pathway to Trouble

This is what the stated goal of the children’s homes has always been. Put another way, it is “breaking the cycle” of the consequences of severe neglect and abuse. But this is very hard to do. It is also hard for caregivers to remember, to keep in mind, that the children they take care of have a story about pain and neglect in their brains. They carry it always, and it can emerge unpredictably in response to current experience. This story will not go away with good care. But it can become increasingly less potent, as a new story is created to take its place. The new story is about acceptance, trust, love, and hope. The new story is about healing.

A Healing Place

I then told them about an 8-year old girl I had observed the day before. Let’s call her “Angela”, not her real name. She entered the home at 3-years old as the victim of severe neglect and abuse, including sexual abuse. After 4 years in the home, she was “reunited” with her family. (It is important to remember that this ill-conceived law, LEPINA, was implemented abruptly, without adequate assessment of the families’ competence as caregivers, and without support for these families in the community.) When in Angela’s case the neglect and abuse began again, her family returned her to Love and Hope, with occasional weekend visits to her family. The day before yesterday, after a recent visit Angela made to her family, we observed her playing. She explained that she was making a “botiquin”. Neither Susana nor I understood the reference, so Susana asked her what a botiquin was. She explained that a botiquin was something that contained whatever you needed to make yourself better when you were hurt. With Rachel’s help, she carefully organized the contents she planned to put into the box when it was completed – band aids, tape, pretend thermometer, etc. Another girl in the home offered to help her with the project and was taping clean white paper onto the cardboard box with all the care of wrapping a present. As I watched this hurt child happily engaged in pretend play with the support of her primary caregiver and her friend, I thought to myself that she was representing in play the safety and comfort of Love and Hope. She was creating for herself a healing place.

Charley Zeanah presented to the group on September 21 and 22. He has been involved in Romania for 14 years. The Romania initiative traces its beginning to a movement started by the 1909 White House Conference on Children that declared its opposition to the institutionalization of dependent and neglected children. Now institutionalization of children whose families cannot take care of them is rare in the U.S., but not in other parts of the world. Romania is a unique story. The research group was invited to study there in the context of a policy debate about what to do with all the children institutionalized by Ceausescu’s government. Under Ceausescu, the official position was that the State could do a better job in raising children than many mothers could, so mothers who were struggling with poverty or other adversities were encouraged to give up their children in the maternity hospital. After several months in the maternity hospital, if the child had no obvious problems, he was transferred to a nursery, where he stayed until 36 months. At that point, if an exam determined him to be normal, the child was sent to a children’s home.

Although there was wide variability in children’s homes, there were some important common features, including many factors working against the establishment of individualized attachment relationships with the caregivers. The children were fed around the table with little or no talking, there was a lot of “free play time” with little support from the caregivers, and aggressive behavior and expressions of distress were often not attended to. Films of this “free play time” revealed painful images of children rocking and spinning.

The study created a model foster home project in which social workers were trained to work closely with the foster families to facilitate attachment and support the foster parents. Interestingly, one of the main effects of this intervention was an increase in IQ of the children in foster families. Also, these children showed greater expression of positive emotion than the institutionalized children within a few months. When assessment was repeated after 42 months in foster families, a community control group had the best attachment to their caregivers, the foster group had medium results, and the institutionalized group had the worst outcome. The children in this last group included a high percentage of withdrawn, inhibited kids with Reactive Attachment Disorder. It is interesting to note that the characteristic “indiscriminate” attachment behavior of RAD persisted even after the group in foster care had formed attachments to their foster families.

Later, when psychopathology was assessed at 54 months, 55% of the children living in institutions had diagnosable psychiatric disorders in contrast with 22% of children in the (control) community group. Both foster care and institutionalized groups had higher levels of emotional disorders (such as anxiety and depression) and behavioral disorders (such as ADHD, Oppositional Defiant Disorder, and Conduct Disorder) than the community group. The improved cognitive outcomes in the foster care children were most significant for children placed in foster care before 24 months. Similar sensitive periods were also found for the development of language, attachment, and indiscriminate behavior. An important finding was that secure attachment at 42 months predicted psychopathological outcome at 54 months. Interestingly, there was a big gender difference, with most of the securely attached children at 42 months being girls and most of the children with psychiatric symptoms at 54 months being boys.

In conclusion, the research group found that children raised in institutions have compromised development across almost all domains, that attachment status moderates many aspects of psychopathology, and that the socio-emotional effect is more profound than the cognitive effect. When you place these children in good foster homes, you get attachment recovery and some – but not all – recovery from psychopathology. The research group strongly recommends intervening in abusive and neglectful caregiving situations as early as possible. More specifically, they propose removing children from institutions and placing them in foster homes.

I noted that this was a beautiful presentation of a study of monumental importance in child development and child psychiatry. The study demonstrates the power of the caregiving relationship to influence development. I pointed out, though, that the Romanian orphanages represent – as Dr. Zeanah explained – a rather unique and extreme caregiving situation, and that there is a problem in that is that this study of Romanian orphanages is being used by some international agencies to promote a one size fits all approach to the problem and laws such as LEPINA in El Salvador that require immediate reunification of institutionalized children with their biological families, with little or no support for their severely disadvantaged and dysfunctional families in the community.

Ed Tronick quoted the “old literature “– the first edition of Jerome Kagan’s book on child development that included accounts of children raised in institutions after WWII. These children did relatively well. How can we explain that? One possible reason is that there was a commitment to these children because of something terrible, morally bad that had been done, enhancing the caregivers’ desire to do something for them. Dr. Zeanah talked about the meaning of the children to the caregivers. In the case of Romanian orphanages, the society’s negative attitudes towards the Roma, who make up of 30% of children in orphanages, though they comprise only 6-9% of the population, may affect the caregivers’ commitment to the children.

Dr. Zeahah said that their group is interested in individual differences in response to institutionalization among the children. He noted that there may be a relationship between certain genotypes and indiscriminate behavior. They are looking at alleles that are very sensitive to experience and those that seem impervious. In that case, if you have the impervious alleles you fare well no matter what the environment and if you have the sensitive alleles you may struggle in an average expectable environment. Readers of the blog will recognize the “orchids versus dandelions” metaphor.

Apropos these last comments, I had a number of thoughts. First, I would underscore the importance of the meaning of the child to the caregivers. For example, a religious or spiritual mission to minister to children in need may allow caregivers to see the child as deserving of loving care and to recognize the unique value of each child, while also sustaining the caregiver through the frustrations and disappointments involved in their tasks. For example, the message that each child is precious to Jesus – no matter what he looks like or how much he achieves – is a powerful message indeed. It is also important to remember the orchids and dandelions story. This story emphasizes the individual characteristics of each child, including the ability – innate or acquired – to take in the good in their environment and make it part of themselves. These thoughts remind us of the complexity of development and of how important it is to continue to search for a repertoire of solutions so that we can find a unique approach to each unique challenge.

About

Alexandra Murray Harrison, M.D. is a Training and Supervising Analyst at the Boston Psychoanalytic Society and Institute in Adult and Child and Adolescent Psychoanalysis, an Assistant Clinical Professor of Psychiatry, Harvard Medical School at the Cambridge Health Alliance, and on the Faculty of the Infant-Parent Mental Health Post Graduate Certificate Program at University of Massachusetts Boston. Dr. Harrison has a private practice in both adult and child psychoanalysis and psychiatry. In the context of visits to orphanages in Central America and India, Dr. Harrison has developed a model for mental health professionals in developed countries to volunteer their consultation services to caregivers of children in care in developing countries in the context of a long term relationship with episodic visits and regular skype and video contact.